Provider Demographics
NPI:1215128806
Name:TARA N. VAN DE WYNGAERDE, O.D., P.C.
Entity type:Organization
Organization Name:TARA N. VAN DE WYNGAERDE, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:VAN DE WYNGAERDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-539-6291
Mailing Address - Street 1:700 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1412
Mailing Address - Country:US
Mailing Address - Phone:815-539-6291
Mailing Address - Fax:815-539-3035
Practice Address - Street 1:700 14TH AVE
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1412
Practice Address - Country:US
Practice Address - Phone:815-539-6291
Practice Address - Fax:815-539-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5997220001Medicare NSC